What do we mean by 'killing' and 'letting die'?

Ivar R. Hannikainen, Anibal Monasterio-Astobiza, & David Rodríguez-Arias
www.bioxphi.org
Originally published 22 Feb 20

Bioethicists have long asked how to distinguish killing from letting die. Opponents of the legalization of euthanasia routinely invoke this distinction to explain why withholding life-sustaining treatment may be morally permissible, while euthanasia is not. The underlying assumption is that, when physicians refrain from applying life-sustaining treatment, they merely let the patient die. In contrast, a doctor who provided a lethal injection would thereby be 'killing' them. At a broader level, this view implies that 'killing' and 'letting die' are terms we use to distinguish actions from omissions that result in death.

Theorists such as Gert, Culver and Clouser (1998/2015) advanced a radically different understanding of this fundamental bioethical distinction. In a germinal paper, they argue that to 'kill' involves a contextual assessment of whether the doctor violated a prior duty. In turn, whether the doctor violated their duty—namely, to preserve the patient's life—depends on the patient's preferences. (They actually argued for a more sophisticated view according to which only some preferences, i.e., refusals, constrain a doctor's duty—while others, i.e., requests, do not.) This view is qualitatively different from the first (what we call commissive) view. On this alternative view, which we refer to as deontic, 'killing' and 'letting die' serve to differentiate patient deaths that result from breaches of medical duty from those that do not.

How well does each of these theoretical perspectives capture people's use of the killing versus letting die distinction? In a recent paper published in Bioethics, our goal was to develop an understanding of the considerations that carve this bioethical distinction in non-philosophers' minds.

We invited a group of laypeople, unfamiliar with this bioethical debate and lacking any formal training in the health sciences, to take part in a short study. Each participant was asked to consider a set of three hypothetical scenarios in which a terminally ill patient dies, while we manipulated two features of the scenario: (1) the physician's involvement, and (2) the patient's wishes.

The info is here.

Nurses Wrestling With the Moral Uncertainties of MAiD

Barbara Pesut and Sally Thorne
Impact Ethics
Originally posted October 23, 2019

Have you tried to imagine what it is like to be the healthcare provider who provides medical assistance in dying (MAiD)? What would it feel like to go into a strange home, to greet a patient and family, to start an intravenous line, to deliver the medications that rapidly cause death, and then to bring some sort of closure before leaving? Although there has been a great deal of attention paid to the regulation of MAiD, and its accessibility to the Canadian population, we have heard relatively little about the moral experiences of the healthcare providers at the forefront of providing this service. That is surprising in light of the fact that all but 6 of the 6,749 MAiD deaths in Canada that occurred between December 10, 2015 and October 31, 2018 were administered by physicians or nurse practitioners.

In a recent study we interviewed 59 nurses from across Canada, who had diverse experiences with participating in, or choosing not to participate in, the MAiD process. Canada is the first country to allow nurse practitioners to act as both MAiD assessors and providers. Canadian registered nurses also play a key role in providing care to patients and families considering, planning for, or receiving MAiD. We learned a lot about the experiences of being involved in MAiD and about the type of wrestling with moral uncertainty that the involvement can entail. Nurses worked hard to make sense of this radical new end-of-life option. Making sense required some soul searching, some important conversations, and in some cases, encounters with the procedure itself.

Encounters with MAiD were inevitably deeply impactful. Some participants described an emotional overload that was unanticipated and didn’t necessarily fade over time. Others described a deep sense of compassion and purpose—a sense of beauty. Still others described an accumulating sense of distress, a rising tide that they didn’t necessarily know how to deal with. This was particularly true for those nurses who worked alone on multiple cases because they were the sole person willing to provide MAiD. Even those who had experienced MAiD only as observers described an emotional climate within the care environment that was far-reaching.

The info is here.

‘My death is not my own’: the limits of legal euthanasia

Henk Blanken
The Guardian
Originally posted August 10, 2018

Here is an excerpt:

Of the 10,000 Dutch patients with dementia who die each year, roughly half of them will have had an advance euthanasia directive. They believed a doctor would “help” them. After all, this was permitted by law, and it was their express wish. Their naive confidence is shared by four out of 10 Dutch adults, who are convinced that a doctor is bound by an advance directive. In fact, doctors are not obliged to do anything. Euthanasia may be legal, but it is not a right.

As doctors have a monopoly on merciful killing, their ethical standard, and not the law, ultimately determines whether a man like Joop can die. An advance directive is just one factor, among many, that a doctor will consider when deciding on a euthanasia case. And even though the law says it’s legal, almost no doctors are willing to perform euthanasia on patients with severe dementia, since such patients are no longer mentally capable of making a “well-considered request” to die.

This is the catch-22. If your dementia is at such an early stage that you are mentally fit enough to decide that you want to die, then it is probably “too early” to want to die. You still have good years left. And yet, by the time your dementia has deteriorated to the point at which you wished (when your mind was intact) to die, you will no longer be allowed to die, as you are not mentally fit to make that decision. It is now “too late” to die.

The info is here.

Ethical Dimensions of Caring Well for Dying Patients

Ilana Stol
AMA Journal of Ethics
2018;20(8):E678-682.

Dying is a uniquely individual yet deeply shared and universal experience; it profoundly impacts perceptions of culture, personhood, and identity. For many Americans, it is also an experience widely discrepant from the one they want and envision for themselves and their loved ones.  Over the past decade, there has been growing awareness of the incongruence between the way Americans say they want to die and how they actually do.  But while most would agree that this reality is not the ideal that clinicians or patients strive for, what is less agreed upon is what the roles of clinicians and patients should be in defining what actually constitutes dying and good care of dying people. What do patients and clinicians need to know about dying and care at the end of life? What barriers exist to accessing and employing this knowledge in the face of difficult decisions?

To best answer these questions, it is useful to examine the social structures and supports already in place for end-of-life care and to understand how they are being utilized. To begin with, hospital palliative care programs are expanding rapidly in order to meet the physical and emotional needs of patients with serious or terminal illness. Robust evidence now exists demonstrating that early palliative care improves the dying experience for both patients and families while generally reducing health care costs and potentially prolonging survival. Despite these facts, there is significant variation in physician practice in the care of patients at the end of life and a general consensus that palliative and hospice care are underutilized by physicians.

The information is here.